Báo cáo khoa học: "A case of radiation-induced sternal malignant fibrous histiocytoma treated with neoadjuvant chemotherapy and surgical resection" potx

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World Journal of Surgical Oncology
Open Access
Case report
A case of radiation-induced sternal malignant fibrous histiocytoma
treated with neoadjuvant chemotherapy and surgical resection
Bulent Kocer
1
, Gultekin Gulbahar*
1
, Bulent Erdogan
2
, Burcin Budakoglu
3
,
Selim Erekul
4
, Koray Dural
1
and Unal Sakinci
1
Address:
1
Numune Education and Research Hospital, Thoracic Surgery Department, Ankara, Turkey,
2
Numune Education and Research Hospital,
Plastic and Reconstructive Surgery Department, Ankara, Turkey,
3
Numune Education and Research Hospital, Medical Oncology Department,

Ankara, Turkey and
4
Ankara University School of Medicine, Pathology Department, Ankara, Turkey
Email: Bulent Kocer - ; Gultekin Gulbahar* - ; Bulent Erdogan - ;
Burcin Budakoglu - ; Selim Erekul - ; Koray Dural - ;
Unal Sakinci -
* Corresponding author
Abstract
Background: Primary sternal malignant fibrous histiyocytoma (MFH) is highly rare. Effective
treatment modality is surgical resection with wide margins. However, to date, the effects of
radiotherapy or chemotherapy has not been clearly defined.
Case presentation: Herein, we aimed to present a 50-year old female patient with MFH
occurred in the radiotherapy field who had had surgical procedure for breast cancer 19 years ago
and had followed by radiotherapy. Neoadjuvant chemotherapy was applied for MFH due to cardiac
and mediastinal vascular invasion. Wide resection was carried out for the mass after having been
decreased in size following neoadjuvant chemotherapy.
Conclusion: Neoadjuvant chemotherapy was an effective method. In planning the surgical
resection, the size of the tumor before chemotherapy should be considered as the initial size and
surgical margins should be determined accordingly.
Background
Primary sternum tumors are rare entities, almost all of
which have a malignant progression [1]. Chondrosar-
coma is the most common primary sternum tumor[2].
MFH usually results from radiation scar [3]. Effective treat-
ment modality is surgical resection with wide margins.
Radiation-induced MFH is rare and its treatment regards
experience.
Case presentation
A 50-year-old female patient applied with ulcerated and
painful lesion on the sternum (Figure 1). The patient had

the complaints for 3 months, during which the lesion
gradually grew. The personal history of the patient
revealed that she had undergone total modified radical
mastectomy on the left and axillary lymph node dissec-
tion for infiltrative ductal breast carcinoma 19 years
before and received radiotherapy and adjuvant chemo-
therapy. She had also received hormonotherapy for 2
years. In the physical examination, an ulcerated lesion of
5 × 6 cm in diameter, which was fixed on the sternum and
rising above the skin surface, was palpated. In the labora-
tory evaluations, the serum gama-glutamyl transpherase
(GGT) level was 194 U/L and the other biochemical anal-
Published: 30 December 2008
World Journal of Surgical Oncology 2008, 6:138 doi:10.1186/1477-7819-6-138
Received: 16 July 2008
Accepted: 30 December 2008
This article is available from: />© 2008 Kocer et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( />),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
World Journal of Surgical Oncology 2008, 6:138 />Page 2 of 4
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yses and hematological parameters including the tumor
markers were normal. The lateral x-rays showed destruc-
tion of the sternum. Thorax computerized tomography
(CT) and magnetic resonance imaging evaluations indi-
cated a lesion of 5 × 6 cm in size that had caused nodular-
ity on the skin and marked destruction in the sternum
(Figure 2). The diagnosis based on the incisional biopsy
was MFH.
The patient did not have any findings of distant metasta-

sis, but was considered inoperable because of local inva-
sion. A chemotherapy protocol of iphosphamid 2500 mg/
m
2
(3 days), mesna 2500 mg/m
2
(3 days), and adriablas-
tina 50 mg/m
2
(1 day) (IMA) was started with 21-day
intervals. After two cures of chemotherapy, the size of the
lesion was 3 × 3 cm. Repeated thorax CT showed regres-
sion of the local invasion, and the tumor was operable.
Thus, operation was planned.
Treatment
Intraoperatively, the lesion on the corpus stern was totally
excised with a 4-cm margin along with the health tissue.
The manubrium sterni was preserved. To provide stabili-
zation, prolene mesh and methyl methacrylate were used.
Then, the areolar fatty tissue and skin composite transpo-
sition flap was formed and transpositioned on the prolene
mesh. A drain with negative pressure was placed under the
transposition flap. The remaining right breast tissue was
advanced along the inframammarian sulcus and the flap
donor area was closed.
Pathological findings
The histopathological evaluation of the incisional biopsy
material showed a tumor growth of mesenchymal charac-
ter with cellular appearance. The tumor consisted of cells
with spindle character forming non-marked storiform

pattern at certain places and fewer polygonal cells. There
were marked nuclear pleomorphism and common mito-
sis. Atypical mitoses and tumor giant cells with bizarre
nuclei were not infrequent. Necrotic areas were present.
With these properties the tumor was considered as high
grade malignant pleomorphic mesenchymal tumor.
Immunohistochemically, the tumor cells showed strong
cytoplasmic staining with CD68, a histiocyt marker.
Therefore, histopathological diagnosis was MFH. (Figures
3 a-b)
Postoperative follow-up
In the early postoperative period, recurrence was
observed. The patient was applied adjuvant chemother-
apy. In the postoperative 11
th
month, cranial metastasis
was detected and the patient died in the postoperative
13
th
month.
Discussion
Tumors with a sternum origin are a very rare type of pri-
mary thoracic wall tumor. Tumors of the sternum usually
have a malignant nature. The most common histopatho-
logical diagnosis is chondrosarcoma [2]. Although MFH is
the most common soft tissue sarcoma, it is rarely located
on the thoracic wall and particularly on the sternum[4,5].
In a retrospective study of 64 years, nearly half of the 54
patients with primary sternum tumor were diagnosed
with chondrosarcoma, while only one of these patients

(1.8%) was diagnosed with MFH [2]. MFH has been
reported to be more common among patients who have
received radiotherapy [3].
Ionized radiation is clearly known to trigger sarcoma for-
mation [6]. Cahan et al in 1948 defined the criteria for
The ulcerated mass originating from the sternumFigure 1
The ulcerated mass originating from the sternum.
The chest CT image of the patientFigure 2
The chest CT image of the patient.
World Journal of Surgical Oncology 2008, 6:138 />Page 3 of 4
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post-radiation bone sarcoma. The requirements are: (a)
evidence of an initial distinct malignant tumor different
from the subsequent sarcoma, (b) development of the sec-
ond malignant tumor in an irradiated field, (c) long inter-
val between radiation and development of sarcoma and
(d) histological confirmation of sarcoma [7]. This case
report fulfils these criteria.
In establishing histopathological diagnosis, percutaneous
fine needle biopsy is preferred because it is easily applied
and has low risk of complications. However, variable
morphological characteristics of MFH may render diagno-
sis challenging [5]. Nonaka et al have presented a similar
patient in whom the preoperative diagnosis could not be
established through percutaneous needle biopsy and due
to the destruction in the sternum, complete surgical resec-
tion was preferred in the diagnosis and treatment of the
patient [8]. Nevertheless, preoperative histopathological
diagnosis may lead to considerations for different treat-
ment alternatives such as neoadjuvant chemotherapy in

determining a treatment strategy. Unlike percutaneous
needle biopsy, incisional biopsy may provide sufficient
amount of tissue that will facilitate immune staining.
Accordingly, we preferred incisional biopsy in establish-
ing preoperative diagnosis. Neoadjuvant chemotherapy is
applicable particularly in case of lesions with mediastinal
invasion or lesions of extremely large sizes. In our patient,
the size of the lesion was 50% smaller and the findings of
mediastinal invasion regressed upon two cures of neoad-
juvant chemotherapy. This shows that preoperative neo-
adjuvant chemotherapy is an effective method.
Following the diagnosis of malignant primary chest wall
tumors, surgical resection of a wide area is required.
Despite various views on the extent of resection area,
many earlier studies have recommended en bloc resection
of the tumor, covering an area of 4 cm from all the sides
along with the structures such as the lungs, thymus, and
pericardial tissues that may be invaded by the tumor
[9,10]. By reconstruction of the resultant defect, total clo-
sure of the defect and providing structural stability should
be aimed. Any defects of smaller than 5 cm at any location
on the thoracic wall and any defects smaller than 10 cm
on the posterior wall of the thorax can be closed primarily
and usually do not require reconstruction. However,
reconstruction of any larger defects is essential. In achiev-
ing structural stability, methyl methacrylate has been rec-
ommended in addition to Marlex, Mersilene, or Prolene
Mesh, while in covering the defect, the most commonly
used method has been pectoralis major or latissimus dorsi
musculocutaneous flap transposition depending on the

location of the defect [10]. The lesion of the patient was
removed en bloc. In covering the defect, pectoralis major,
and in providing the stability of the chest wall, Prolene
Mesh™ (Ethicon, Inc., Somerville, NJ) and methyl meth-
acrylate were used.
The recurrence in the postoperative any follow-up period
delineates the need for a sufficient resection margin all
around the lesion during the surgery. Neoadjuvant chem-
otherapy can decrease the unnecessary resection around
the mass as the margins of which can be shrunken after
the neoadjuvant chemotherapy. In our patient, the diam-
eter of the tumor decreased by 3 cm and findings of inva-
sion to the mediastinal structures disappeared after
neoadjuvant chemotherapy. It seemed that en bloc resec-
tion of the tumor with a vital tissue margin of 4 cm was
not totally sufficient in our case due to recurrence after
A) The tumor consisted of cells with spindle character forming non-marked whirlpool-like structures at certain places and fewer oval cells (H&E.200×)Figure 3
A) The tumor consisted of cells with spindle character forming non-marked whirlpool-like structures at cer-
tain places and fewer oval cells (H&E.200×). B) It has been observed that tumor cells were strongly stained with CD68
immunohistochemically (CD68 200×).
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World Journal of Surgical Oncology 2008, 6:138 />Page 4 of 4
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surgery although the size of the tumor had gotten smaller
after neoadjuvant chemotherapy. Perhaps, the preopera-
tive size of the tumor should have been considered as the
basal measurement, and the decision for the resection
extent should be marked as 4 cm vital tissue encircling the
original mass before chemotherapy. Taking this into con-
sideration, resection margins should have been like 7 cm
of vital tissue from the center of the original mass in our
case.
Conclusion
Neoadjuvant chemotherapy was an effective method in
this related case, and we recommend its use in such cases.
In planning the surgical resection of the tumor after neo-
adjuvant chemotherapy, when possible, the size of the
tumor before chemotherapy should be considered as the
initial size and surgical margins should be determined
accordingly. Complete surgical resection is the desired
outcome after neoadjuvant chemotherapy which might
provide downsizing as happened in our case saving vital
tissues to be resected. En bloc resection of the tumor occu-
pying an area of 4 cm vital tissue apart from all along the
wound margins with the structures such as the lungs, thy-
mus, and pericardial tissues that may be invaded by the
tumor. Afterwards, total closure of the defect by recon-
struction using synthetic materials like meshes should be
provided to protect the structural stability.

To sum up, it seems neoadjuvant chemotherapy is an
effective method in MFH cases before performing surgical
resection. Besides, we believe that further studies about its
indication are still being warranted in large series in this
field.
Abbreviations
MFH: Malignant fibrous histiyocytoma; CT: Computer-
ized Tomography.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
BK was involved in study conception and design and
reviewing previous research. GG was involved in scquisi-
tion of data and drafting of manuscript. BE was involved
in study conception and design. BB was involved in study
conception and design. SE was involved in study concep-
tion and design and preparing photographs. KD was
involved in analysis and interpretation of data. US was
involved in critical revision and project coordination.
Acknowledgements
Each authors certifies that he has no commercial associations that might
pose conflict of interest in connection with the submitted article. All fund-
ing sources of the study supported by authors. Each authors declares that
patients consent has been received.
We would like to express our gratitude to Erkan Yildirim MD, FETCS for

his valuable revision and correction of english grammatical and typographi-
cal errors throughout the manuscript.
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